SIGNIFICANCE OF TWO-DIMENSIONAL SHEAR WAVE ELASTOGRAPHY IN PREDICTING ESOPHAGEAL VARICOSE VEINS DURING CHRONIC LIVER DISEASE.

The aim of the study was to reveal diagnostic capabilities of 2D SWE for predicting esophageal varices (EV) in patients with chronic liver diseases. This case-control study included clinical-laboratory examination results data of 104 patients which were collected retrospectively at the medical center from January 2020 to April 2022. 52 patients who were participated in the examination had got chronic liver disease (case group), and 52 patients were healthy (control group). Based on the obtained data, we compared 2D SWE results with esophagogastroduodenoscopy (EGD) results and evaluated the diagnostic value, sensitivity, specificity, AUROC, positive predictive value (PPV) and negative predictive value (NPV) of 2D SWE in the presence of esophageal varices. A total of 104 patients were included in the examination. Average hardness of the liver of healthy patients was 3.98 Kpa, the average hardness of the liver in patients with chronic liver disease was 17.51 Kpa. Sensitivity and specificity of liver elastography were 100% and 76%, respectively;(AUROC: 0.973); In addition, positive and negative predictive values were 40% and 100%, respectively. 2D SWE of the liver, as a non-invasive method of evaluating liver stiffness during chronic liver disease, can also be used to predict the presence of esophageal varices.

MANAGEMENT OF ESOPHAGEAL PERFORATION: A CASE REPORT.

Esophageal perforation (EP) is a devastating condition. In modern times it is still associated with substantial morbidity and mortality. 62-year-old male patient came to Surgical Department of the First University Clinic of Tbilisi State Medical University on 17.10.2018 15:00. The patient complained of pain in the chest cavity, especially after eating, shortness of breath, fever, chills, weakness. The patient felt pain in the chest cavity after eating 4 days before hospitalization. CT scan revealed pneumomediastinum, extravasation of contrast medium at the level of the 8th thoracic vertebra. Esophagogastroduodenoscopy revealed a defect in the esophagus at the level of 32 cm from the incisors. Dimensions of defect were 2.0 - 3.0 cm. An urgent operation was performed. Left-sided posterolateral thoracotomy, mediastinotomy, suturing of the defect, buttressing of the sutures with the mediastinal pleura, washing and drainage of the mediastinum and left pleural cavity were performed. A Witzel gastrostomy was performed. After the operation, the patient's treatment continued in the intensive care unit. Since leakage was noted, it was decided to place an esophageal stent in the area of the defect. Stenting was performed on 05.11.2018. A complication in the form of bleeding was noted on 01.12.2018. Bleeding was controlled conservatively. Finally, stent was removed and the patient was discharged from the clinic in good condition on 07.12.2018. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation. Surgery should be undertaken in all patients who do not meet non-operative management criteria. Buttressing the esophageal repair with surrounding viable tissue has been recommended to decrease the risk of leakage. If direct repair of thoracic EP is not feasible esophageal exclusion, diversion, or resection should be performed. Repair over a large size T-tube can be used to create a controlled esophago-cutaneous fistula and minimize mediastinal and pleural contamination. Thus, esophageal perforation continues to present a diagnostic and therapeutic challenge despite decades of clinical experience and innovation in surgical technique.

DESARDA TECHNIQUE FOR INGUINAL HERNIA REPAIR.

Worldwide, more than 20 million patients undergo inguinal hernia repair annually. The problem of our age is to find an operation that is simple, does not require implantation of a foreign body like mesh and does not produce major complications during or after surgery. We represent 118 male patients who underwent hernioplasty by Desarda method between 2008 and 2017. 84 were elective and 34 - acute patients, respectively. Hernias in 26 cases were direct, 88 - indirect. Among elective cases 2 patients had bilateral hernia. 2 elective patients had recurrent hernia. There were 6 scrotal hernias, 13 - sliding hernia cases among elective patients. The age of patients was from 18 to 86 years. 33 patients were aged 70 and over. Among these 33 patients 12 had severe comorbidity of circulatory, respiratory systems and/or other diseases. Mean operating time was 42.43±2.8 min. There were no intraoperative complications. Postoperative pain according to VAS (Mean ± SD) on day 1 was 31,27±0.86. No patient had discomfort for more than 15 days after this repair. Among postoperative complications there were not any severe complications. No chronic pain, sensation of foreign body and no recurrence was observed. The mean hospital stay was 1.87±0.78. According to our experience Desarda method seems to be an attractive alternative of other methods widely adopted today. Desarda repair has the potential to become the gold standard of hernia repair.

TREATMENT OF DUODENAL INJURIES AND COMPLICATIONS AFTER SURGERY (CASE REPORTS).

A 28-year-old male patient came to Surgical Department 15.07.2003 after a gunshot wound. An emergency operation was performed. Among the other damages of different part of intestinum damage of the anterior wall of the second anatomical part of the duodenum was diagnosed intraoperatively. The size of the damaged area was 3×1 sm. The doudenal wound was sutured with two layers after updating the edges. On the fifth postoperative day the wound leakage was detected. Later the giant sizes of duodenal fistula was formed. It opened on the anterior wall of the abdomen. After patients proper preparation there was performed the operation after 6 months of initial operation. Operative access was laparotomy from right pararectal incision. The mobilization of the edges of this fistula was performed without entering the abdominal cavity. The first loop of the jejunum was constructed in Roux-an-Y form. There was formed subcutaneous canal and distal part of Roux-an-Y type constructed jejunum was passed through it. There was performed mobilization of the edges of anterior part of aponeurosis of the rectus muscle sheath nearby of the fistula. End-to-End anastomosis was performed between fistula and Roux-an-Y type constructed jejunum. Postoperative period passed without complications. A 45-year-old male patient came to Surgical Department 26.11.1992 after a car accident. After different types of investigations was diagnosed damage of the retroperitoneal wall of the third part of the duodenum. The size of the wound was 2×1 sm. An urgent operation was performed. After Cocher's maneuver a wound was found and sutured. On the postoperative day 4 passage of the duodenal content through the drainage was detected. Retroperitoneal phlegmon with severe intoxication was diagnosed. In reoperation duodenotomy was performed proximally to the damaged area. Duodenum was ligated distally from papilla Vateri. There was performed anastomosis proximally from the ligature between already formed duodenotomy area and distal part of jejunum constructed in Roux-an-Y form. The patient's condition improved the second day after surgery. Thus, according to our experience, there are no standard solutions of treatment of duodenal injuries and postoperative complications. In both cases we adopted non-standard decisions. In accordance with the received good results, we may recommend described operations as the acceptable treatment methods in specific cases.

HYPOGENESIS OF RIGHT LOBE OF LIVER ACCOMPANIED BY PORTAL HYPERTENSION AND ESOPHAGOGASTRIC VARICEAL BLEEDING; A RARE ANOMALY: A CASE REPORT.

Hypo-agenesis of the right lobe of the liver is an extremely rare finding. It is defined as the complete or partial absence of liver tissue on the right side without previous disease or surgery. It is usually an incidental finding. A 32-year-old female patient came to Emergency Department of TSMU the First University Clinic 22.10.2015 with an initial diagnosis of upper gastrointestinal bleeding. Her medical history showed no previous diseases of the liver or episodes of hemorrhage. Dizziness, nausea, vomiting with red blood, melena was presented on admission. Esophagogastroduodenoscopy revealed III degree varicose of veins from middle part of the esophagus to cardiofundal part of the stomach. Hemorrhage was observed from cardial part of the stomach. Control of bleeding was not achieved endoscopically. Sengstaken-Blakemore tube was used to stop bleeding temporarily. Computed tomography with angiography was performed. Right lobe of the liver was presented with VII and VIII segments. Medial edge of the left lobe of the liver is located near the spleen. Liver parenchyma is homogenous. No thrombosis of the portal or hepatic veins was revealed. Gallbladder was dislocated laterally and cranially without pathological changes. Extra- and intrahepatic biliary ducts were not dilated. There was colonic interposition between the liver and diaphragm. Diagnosis was established - hypogenesis of right lobe of liver, atrophy-hypertrophy complex, portal hypertension, varicose of the veins of the esophagus and cardiofundal part of the stomach, hemorrhage from variceal vein of the cardial part of the stomach, acquired coagulation factors deficiency, functional hypersplenism, posthemorrhagic anemia. In our case there was congenital hypogenesis of the right lobe of the liver. Five months follow-up showed no recurrent bleeding.

Miniinvasive surgical management of cholelithiasis for elderly and senile patients: a retrospective study.

The aim of the present study is to analyze outcomes after laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) for gallstone disease and determine the algorithm of treatment for elderly and senile patients according to the age, severity of disease and comorbid conditions. This is a multicenter retrospective review of 906 elderly and senile patients who underwent LC or MC between January 1, 2002 and December 31, 2008. The patients were categorized into LC (444) and MC (462) groups. When preoperative examination data were not reliable, we performed abdominal wall lifting with the retractors to visualise abdominal cavity with laparoscope during minilaparotomy. There were statistically significant differences in mean operating time (82 and 60 minutes in LC and MC, respectively) (р<0.001), mean duration of usage of non-narcotic analgesics postoperatively in elderly patients (1.5 and 1.1 days in LC and MC, respectively) (р<0.001), intraoperative complications (11 LC and 2 MC cases) (p=0.02), postoperative complications in senile patients (36 LC and 22 MC cases) (p=0.039) and in mean hospital stay for elderly patients (1.7 and 1.3 days in LC and MC, respectively) (p=0.025). MC is an attractive alternative of LC, especially for elderly and senile patients, with their high incidence of acute cholecystitis. MC is effective, safe and optimal operative procedure. Especially, it is important for countries with lower economic capacity.

[Prevention of errors and complications in formation of esophageal layer-by-layer apparatus anastomosis].

The aim of the research is to analyze the outcome of treatment of patients with cardioesophageal cancer. Subtotal resection of esophagus with gastrectomy was performed on 3 patients. On 9 patients the resection of esophagus with gastrectomy from left thoracophrenolaparotomy was performed. Gastrectomy with resection of abdominal part of esophagus was performed on 10 patients. Transhiatal mediastinal lymphadenectomy S2D2 was carried out in all cases. The esophageal anastomosis has been formed by circular apparatus EEA and SPTU. The functional condition of anastomosis was investigated by X-ray, endoscopical and endo-sonographical methods in the postoperative period. The complications caused by technical errors of esophageal anastomosis were reviewed. The regeneration of circular anastomosis depends of adequate blood supply of anastomosis, observance of safety rules of imposing circular anastomosis. Reasonable application of circular apparatus, the refined technics of imposing anastomosis, X-ray, endoscopical and endo- sonographical research methods decrease complications and promote recovery.

Advantages of mini-laparotomy approach in treatment of acute destructive cholecystitis.

The aim of the present work is to reveal the advantages of laparotomic cholecystectomy by mini access. 1152 patients with cholelithiasis from 17 to 83 years old were operated during 2001 - 2007 (913 - female; 239 male). 85 were more than 70 years old; average duration of operation was 30 - 40 min. Of 1152 operations - 319 operations were performed for destructive forms of acute cholecystitis. There were 225 cases of phlegmonous forms. 94 operations were performed because of gangrenous form. Once we widened the mini-incision to 10 sm. There was 1 case of lethality. We didn't meet serious complications in the other cases. The number of average bed - days was 1-2. Patients return to usual social and working activity in a short time. Thus, mini-laparotomic technology is a convenient and quite universal and, what is the most important, a reliable method of treatment of cholelithiasis and destructive forms of acute cholecystitis. With introduction of mini-laparotomic technologies the expenses for treating are reduced. It allows to get good results of treatment. According to our estimation and literary data MC's economic effects are 8-10 times more as compared to LC's and 5 times more than of a TC's. This is the operation of choice in treatment of acute destructive cholecystitis with good postoperative and remote results. Given method has many advantages and deserves application even in the situation when LC is contraindicated, that allows to save the mini-invasion as an idea.

[Through transhepatic drain during mechanical jaundice caused by secondary sclerosing cholangitis].

37 patients treated for mechanical jaundice caused by secondary sclerosing cholangitis were included in the study. In the study group (20 patients) biliary duct was drained by through transhepatic drainages, in control group (17 patients) this was done by Eåhr and Vishnevsky method. Through transhepatic drain of biliary tree (postoperative complications were developed in 50% of cases, lethality-20%) performed during secondary sclerosing cholangitis, carrying out frame function, prevents further sclerosing of biliary duct and has appeared to be much more effective to remove the jaundice, cholangitis and liver insufficiency in comparison with the drain by Eåhr and Vishnevsky (postoperative complications were developed in 70,6% of cases, lethality-41,2%).

Aspects of aging in georgian traditional medicine.

The goal of the investigation was studying Georgian medicinal manuscripts of X-XVIII centuries in order to find out ideas of ancient authors regarding peculiarities of healthy lifestyle from the moment of birth till the elderly age. Results of analysis of Georgian medieval medicinal manuscripts allow us to conclude, that Caucasian longevity is determined not only by genetic, ecological, social and hygiene factors, but also by rational diet, proper treatment, remedies of plant origin and healthy lifestyle, existing in Caucasian cultural anthropology. Original schemes of diets and recipes, based on humoral theory and balanced by main characteristics of natural material are described.